By and For Those With Private Disability Claims

Living With A Disability — Waiting To Get Better?

Most Americans are conditioned to learn about “work ethic” from a very young age and will attempt to remain at their jobs against insurmountable odds of physical disability. Despite what disability insurers will have you believe, most workers in America are reluctant to leave their only source of financial security until working is no longer an option. Unfortunately, remaining at work too long can also be problematic from both an employment and disability claim perspective.

As a consultant, I’ve heard many, many stories from insureds and claimants praising the support they received, at least initially, from their employers. Employees who worked for the same employers for many years may, in fact, have the sympathies and support of Human Resources, but it is usually short-lived when it becomes evident employees transition to long-term disability and won’t be going back to work. In other words, what employees initially perceive as an employer positive support system is of very short duration, leaving decisions of whether or not to file disability claims entirely up to the employee.

For most employees diagnosed with a disabling disease there are two factors which actually work against favorable disability claims decisions. First, is what I call the “what changed defense.” Although most future insureds try to stay at work much longer than they should, disability insurers will always comment and ask, “Since you were able to work for two years with your impairment what changed to now cause you to file a disability claim?”

Some denial letters I’ve read actually cite the “what changed defense” as a cause for terminating claims. Other internal medical reviewers use the same rational to claim there is no basis for “not now working, since you were able to work before.”

The “what changed defense” always seemed a ridiculous argument to me since insureds can easily explain that they were able to continue working with a worsening condition until such time as it was impossible to “hang in there any longer.” Makes sense, doesn’t it?

Unless a disability is a catastrophic event, disabilities precluding work capacity do not occur overnight, but are more of a gradual progression of physical illness increasing restrictions until continuing on the job is no longer an option. Still, disability insurers will use the “what changed defense” to allege that since insureds were able to work impaired, they should be able to continue doing so. Although most workers attempt to remain on the job to the detriment of job performance in some cases, continuing to work impaired expecting health issues to improve, or go away, isn’t always the right choice.

Secondly, nearly every claimant who contacts me describes a psychological longing, or mourning of their lost jobs, careers or professions. Americans spend a great deal of time and money preparing for their eventual career endeavors and are indoctrinated to associate “who they are by what they do for a living.”

When the career or job functions cease due to disability, there is a loss of identity and self that produces sadness, helplessness, and depression. Nearly every insured or claimant I have ever spoken to in two decades describes feelings of loss of self followed by the eventual optimism of “I know I’m going to get better and be able to be productive again.”

Permit me to describe a recent situation where “should I stay at work, or should I go” may not turn out very well. Nearly a year ago DCS was contacted by a worker who was having extreme difficulty at work and wanted to discuss with me whether he should stay at work, or file a disability claim. His employer approved work accommodations and he decided to remain at work as long as he could. A year later, I received a call from the same individual who told me he received notice his employer eliminated his job. Now, he wanted to file for disability.

This is a clear case when “staying on the job too long” creates obstacles to a successful disability claim. No doubt this employee’s group insurer will allege he is filing for disability, not because he cannot work, but because his employer is terminating him. In addition, the insurer will pull out the “what changed defense” and answer its own question — job elimination, not disability is what changed.

Other examples in the DI category include self-employed individuals who, on their own, stop working for 6-8 months (sometimes years) thinking they are going to get better before filing disability claims. Insurers will subsequently raise issues of “prejudice” and “late filing” when applications are submitted. Also, since DI policies are income replacement coverage, insurers will also ask, “If you haven’t worked for a year, what income is there to replace?”

Decisions to either stay impaired on the job, or leave and file disability claims are sometimes difficult. Although employers can make life challenging for those requiring work accommodations they can’t actually force employees to go out on disability. In addition, unless the company disability Plan is self-insured, employers have very little influence on insurers to pay claims; workers need to take this into consideration when pressured by employers to leave work and file for disability.

Most disability policy definitions permit the payment of disability (for the first 24 months in group plans) if employees are unable to perform the material and substantial duties of their own occupation. Perhaps employees should listen carefully to their physicians who recommend cessation of work for a period of disability. Each work and claim situation is different, but staying at work because of the expectation of “getting better” could mean having to leave work, and not having disability benefits.

Employers should not be exclusively depended on to make choices for you, nor should they be expected to remain permanent support systems when it’s clear returning to work isn’t an option.

It is a very difficult decision to make for workers to either remain on the job working impaired, or filing disability claims, thus giving up everything they have worked so hard for. The loss of a lifetime career is very difficult for Americans to easily accept.

Still, remaining at work too long can pose problems that can’t be easily explained or fixed when eventual disability claims are filed. Insurers will use every argument to challenge the payment of claims and unfortunately not many insureds are aware of the “what changed defense.”

If you stay at work too long, disability insurers will want to know how it was that you were able to work impaired, but can’t work now. This is definitely something worth thinking about.